1. Mammography Screening Information for Providers Indian Health Service National GPRA Team

2. GPRA Measure 8: Mammography Screening GPRA Measure: “Proportion of eligible women who have had mammography screening within the previous two years.” FY 2006 goal: “During FY 2006, maintain the proportion of female patients ages 52-64 who have had mammography screening within the last two years at the FY 2005 level.” As GPRA data “looks back” two years, this means that all women ages 50-64 are included in the measure. Age range of 50-64 is for GPRA tracking only; screening of younger and older women is also appropriate.

3. Clinical Background Contents: – Breast Cancer Statistics/Facts and Figures – Breast Cancer and AI/AN women – Mammography Screening Impact on mortality USPSTF and CDC recommendations Mammography screening rates and variations – AI/AN disparities in screening rates – Data Entry Issues

4. I. Breast Cancer Statistics Breast cancer is the second most commonly diagnosed cancer among American women, after skin cancer. Breast cancer is also the second leading cause of cancer death among U.S. women, after lung cancer.

5. Breast Cancer and Age Breast cancer incidence and mortality rates increase with age. Between 1998 and 2002, 95% of all new cases and 97% of breast cancer deaths occurred in women age 40 and older. During this period, the median age at the time of diagnosis of breast cancer was 61 years.

6. II. Breast Cancer Among AI/AN Women Between 1998 and 2002, the breast cancer incidence rate AI/AN women was 54.8/1000 and the mortality rate was 13.8/1000 Although the incidence of breast cancer among AI/AN women is lower than that of other racial and ethnic groups, breast cancer is still the second leading cause of cancer death among AI/AN women.

7. Breast Cancer Among AI/AN Women Moreover, while the incidence rate of breast cancer among AI/AN women is lower than all other groups, mortality rates are still higher than one group- Asian Americans. AI/AN women diagnosed with breast cancer have lower 5-year survival rates compared to whites, because their cancers are less likely to be found in earlier stages.

8. Breast Cancer Among AI/AN Women Alcohol consumption, low levels of physical exercise and obesity, health risks often found in the AI/AN community, have been linked to increased risk of breast cancer.

9. III. Mammography Screening Mammography is the best way to detect breast cancer in its earliest, most treatable stage—an average of 1–3 years before a woman can feel a lump. Mammography also locates cancers too small to be felt during a clinical breast examination. Mammography detects an average of 90% of breast cancers in women without symptoms.

10. Regular mammography screening reduces breast cancer mortality rates Thanks to more widespread use of mammography and improved treatment, since the late 1980s, breast cancer mortality rates have declined among women of all races. Between 1990 and 2002, the overall breast cancer death rate declined 2.3% each year.

11. Regular mammography screening reduces breast cancer mortality rates One major review study found an average 24% percent mortality reduction associated with regular mammography screening. According to the CDC, regular screening of women ages 40 and over could reduce breast cancer mortality by approximately 16% overall, and up to 30% for women over age 50.

12. US Preventative Services Task Force conclusions on mammography In 2002, the US Preventative Services Task Force concluded there was fair evidence that mammography screening every 1-2 years could reduce breast cancer mortality by approximately 20 percent to 25 percent over 10 years for women age 40 and over.

13. CDC recommendations for screening in women over age 50 The CDC recommends that women between the ages of 50 and 74 receive a mammogram every 1-2 years. Because 77% percent of all diagnosed cases of breast cancer are among women aged 50 years or older, biennial screening of women between the ages of 50 and 69 has been shown to be a particularly cost-effective way to decrease the breast cancer mortality rate.

14. Mammography screening rates: overall According to the Behavioral Risk Factor Surveillance System (BRFFS), in the year 2000, 62.2% of all women age 40 and over had received mammography screening. In the year 2002, 80% of women age 50 and over reported having had a mammogram in the past two years.

15. Differences in mammography screening rates Women with less than a high school education, without heath insurance, or members of an ethnic minority were less likely to have had a recent mammogram.

16. IV. Mammogram screening rates among AI/AN women American Indian and Alaska Native women report significantly lower screening rates than other races. According to the CDC: – 71.4% of white women age 40 and over reported having a mammogram within the past two years. – 47.3% of AI/AN women age 40 and over reported having a mammogram within the past two years.

17. Mammogram screening rates: disparities, cont. Another survey found that 46% percent of American Indian and Alaska Native women aged 50 years and older had received a mammogram in the past 24 months. The national IHS mammography screening rate was 41% in FY 2005.

18. Effects of lower screening rates Although breast cancer incidence rates have declined slightly in AI/AN women in recent years, the mortality rate has not gone down. From 1992 to 2002, death rates from breast cancer declined annually by: – 2.4% for whites – 1.8% for Hispanics – 1.0% for African Americans and Asian Americans – 0% for American Indians and Alaska Natives

19. Effects of lower screening rates AI/AN women diagnosed with breast cancer have lower five-year survival rates in comparison to U.S. whites, mainly because their cancers are less likely to be found in earlier stages. Their cancers are more likely to be found in the “distant” stage, which has a much lower survival rate.

20. More frequent screening allows for earlier diagnoses Earlier and more frequent screening will result in earlier diagnosis and improved survival for Indian women. The death rate from breast cancer could be reduced by more than 30% in American Indian women if current recommendations for biennial screening were followed.

21. Screening should not be limited to women 50-64 There are some situations, including a strong family history of breast cancer, that call for earlier screening, starting at age 40 or younger. Screening mammograms are still appropriate for many women over 65, and are recommended by the CDC and USPSTF. Diagnostic mammograms should be done at any age for clinical indications.

22. Mammography at the IHS Since we understand how important regular mammography screening is, how can we improve screening rates?

23. Mammography Screening at IHS Percentage of eligible women (active clinical patients) who have received a mammogram within the past 2 years: – 2003: 40% – 2004: 40% – 2005: 41% Healthy People 2010 goal is 70%; this is the IHS 2010 goal for this measure as well.

24. Barriers to higher rates Funding: Mammograms are often paid for from Contract Health Service funds, and these funds are often depleted before the end of the year. Patients: Education, Outreach, and Provider Referrals.

25. How can programs improve their mammography screening rates? Making mammograms Priority 1 CHS services can increase the rate. The cost of making mammograms Priority 1 is relatively small in states with the CDC Breast and Cervical Cancer Early Detection Programs, and in states with presumptive Medicaid eligibility.

26. CDC National Breast and Cervical Cancer Early Detection Programs CDC Program Contact List: http://apps.nccd.cdc.gov/cancercontacts/nbc cedp/contactlist.asp IHS CDC Contact: Lauren Tancona ciy6@CDC.GOV ciy6@CDC.GOV

27. How can programs improve their mammography screening rates? Improve clinical access generally with evening and Saturday clinics Improve clinical provider productivity expectations Discuss the goal of improving mammogram rates with the SUD. Send a memo to CHS to let them know what the goal is, adding a rough estimate of the expected expense to CHS for covering mammograms as a Priority 1 service.

28. How can programs improve their mammography screening rates? Patient outreach – CRS software allows providers to identify patients due for a mammogram screening – Patient reminders can be sent to patients due for a mammogram – Providers should remember to refer ALL eligible women for a mammogram Patient education on the importance of regular mammography screening, even for asymptomatic women

29. Importance of provider recommendations Provider recommendation is one of the strongest predictors of mammography use. – One study found that “the most frequent reason cited by women for failure to have mammography is that a physician did not recommend one.” – Another study found that “94% of women whose physicians had recommended mammograms had had one in the last 2 years, while only 36% of women whose physicians had not made the recommendation had had a mammogram.”

30. Data Entry issues Importance of data entry in CRS. Good data entry requires a trained and stable workforce. Mammograms obtained elsewhere can be recorded on PCC as “historical” data. Active patients who have had a mammogram recorded on their chart and coded properly will “count” toward a program’s mammography rate, regardless of where the patient obtained the mammogram.

31. Women’s Health Package Users If a site is participating in CDC’s Early Breast and Cervical Cancer Detection Program, the Women’s Health coordinator can indicate this when setting up the Women’s Health application at the site. Women’s Health Package users can enter income information for patients to see if they are eligible for CDC reimbursement for Pap Smears and/or Mammograms. The program calculates whether the patient is eligible for reimbursement. This helps participating sites track the patients for whom they can expect reimbursement.

32. IHS Contacts Carolyn Aoyama, HQ (Measure Lead) Carolyn.Aoyama@ihs.govCarolyn.Aoyama@ihs.gov Francis Frazier, HQ (GPRA Lead) Francis.Frazier@ihs.govFrancis.Frazier@ihs.gov Theresa Cullen, OIT Theresa.Cullen@ihs.govTheresa.Cullen@ihs.gov Nathaniel Cobb, OPHS Nathaniel.Cobb@ihs.govNathaniel.Cobb@ihs.gov David Espey, OPHS David.Espey@ihs.govDavid.Espey@ihs.gov Cynthia Gebremariam, OIT Cynthia.Gebremariam@ihs.govCynthia.Gebremariam@ihs.gov Amy Patterson, CAO Amy.Patterson@ihs.govAmy.Patterson@ihs.gov